The Mexican Ministry of Health has adopted the strategy of incorporating non-physician providers into the health system for the provision of obstetric care, but has limited data to inform the implementation process for this policy at the operative level. Recent quantitative evidence shows that Mexican-trained midwives and obstetric nurses perform at a similar level or even above that of general physicians in process indicators of obstetric care and their patients have similar neonatal and obstetric outcomes [10, 11]. Yet, incorporating these non-physician providers presents challenges to the health system in terms of resistance by current health provider cadres and managers, frequently due to unfamiliarity with these other provider types, lack of clarity regarding optimizing human resources at the primary, secondary and tertiary levels, and differences in approaches to care.
All provider types interviewed expressed confidence in their professional training and acknowledge that both professional midwives and obstetric nurses have the necessary skills and knowledge to care for women during normal pregnancy and childbirth, each with different technical strengths and characteristics. The three types of providers recognize limits to their practice, namely in the area of managing complications.
We detected differences in how each type of practitioner perceived the concept and process of birth and their role in the process. Professional midwives clearly prioritized humanistic care during childbirth and aimed at creating a natural birth experience. The model of care provided by obstetric nurses lays somewhere in between: warm treatment and respectful care is emphasized at all times, considering the patient wishes regarding childbirth, yet also placing importance on the clinical procedures and hospital protocols. They have a similar clinical perspective to physicians, and therefore have an easier time when communicating with them. GPs viewed the birth process as something to be controlled where something may go wrong at any time; they did not appreciate the autonomy and rights of the laboring women, a perspective documented elsewhere . They also had the limitation of being trained and working within a system that reinforced this view, making adopting a different perspective even more difficult. These varied perspectives were clearly illustrated by their different approaches to obstetric practices such as conducting episiotomies, pain management and uterine wiping, as well as their interaction with the patients. PM and ON training specifically incorporates perspectives and practices which fosters an approach that respects the rights and autonomy of the woman and aims to create a respectful environment for their birth; these competencies and concepts are lacking in the physician training. It is time for women’s autonomy and respectful care to be prioritized, particularly in poor, rural communities. The midwifery model seems the most likely to achieve this goal.
The barriers faced by professional midwives and obstetric nurses are at the individual, hospital and system level: general physicians question their ability and training to handle deliveries, in particular those that become complicated, and the midwifery model particularly as it relates to a clinical setting, is also questioned. The slower-paced, humanistic model of birth is not always seen as feasible in a busy hospital setting. Nonetheless, managing patient autonomy and being respectful is always of upmost priority and does not take any additional time on the part of the provider.
There is debate at the national level regarding integrating midwives into primary, secondary and tertiary levels. While some admit that there may be a role for midwives at the hospital level, some providers (obstetric nurses in particular) believe that given the emphasis on integration at the community-level during the midwives’ training, a better fit would be at the primary health care level. The scarcity of jobs for either provider, and for physicians, likely contributes to this friction about the appropriate place and roles for the non-physician providers.
Many of these barriers arise from physicians’ limited exposure to these other models of care. All midwives and obstetric nurses who had experience working in a medical setting have had to work to prove their capacity to the physician colleagues and to protect their model of care. After having the time to observe these other providers, physicians have come to understand and respect their models of care. In particular, midwives must work even harder to differentiate themselves (in the eyes of the physician) from the traditional midwife, while respecting the training by this provider. The tension within the existing hierarchies of medical and non-physician providers has been observed in many other countries as well [16–18].
Finally, there is the opportunity to significantly impact quality of care by introducing PMs and ONs at the primary care level. Currently, rural, primary care clinics depend on the work of pasantes during their social service year and those who have recently completed their medical studies. This strategy automatically challenges continuity of care, as none of these young physicians stay at their site for more than 12 months. Additionally, these young doctors receive very little supervision and are expected to independently attend deliveries and identify obstetric complications with their limited experience. Incorporating PMs in particular into these health centers has clear benefits. Many PMs come from rural, indigenous areas and are keen to return to their communities. Additionally this cadre receives training on working at the community level and is skilled at community outreach and navigating the cultural aspects of working in rural areas.
The main limitation in the design of this study is that there are few hospital-level settings in Mexico where non-physician providers are practicing and providing obstetric services. As a result, we resorted to a convenience sample and findings may not be representative, in particular as related to the physicians. We did include the main practice training sites for midwives and obstetric nurses for this study. However, in 2010, in Atlacomulco, in the state of Mexico, a maternity hospital was inaugurated that is staffed entirely by obstetric nurses and peri-natal nurse specialists (obstetric nurses with an additional year of specialty training). Any complicated cases or those requiring cesarean section are referred to the local general hospital . This effort is to be commended and deserves close monitoring and evaluation. As with any new health policy, the results of incorporating ONs and PMs into the health care system should be closely monitored and evaluated to estimate the impact on maternal and neonatal outcomes as well as make adjustments to the policy to ensure that this strategy optimizes care.